Please
print and mail, fax, or bring in to Big Dan's Insruance Agency.
I, ______________________________________ request the following changes
be made to my policy.
Print Name
Effective Date of Change/s: ____________________________ Policy Number:__________________
Add Driver
- Name _______________________________________________________
- License Number _______________________________State____________
- Date of Birth __________________________
Add Driver
- Name _______________________________________________________
- License Number _______________________________State____________
- Date of Birth __________________________
Delete Driver
- Name _______________________________________________________
Delete Driver
- Name _______________________________________________________
Please read and sign below.
It is understood and agreed that the requested changes are not valid
unless submitted in writing (signed by the named insured) with all
necessary documentation and appropriate premium and/or fees paid.
Any change/s to a policy can result in increased premium and/or fees
charged by the insurance company (especially "Add Driver"
changes). The Broker may also charge a fee (disclosed on the Broker/Customer
Agreement). It is the Customer's responsibility to be aware of and
submit correct documentation along with sufficient funds to facilitate
changes requested of the Broker. Customer agrees they are responsible
for all fees and premiums and if not submitted at the time of this
change request the Broker and/or the insurance company will bill them
for such. All changes must be acknowledged and accepted in writing
by your insurance company. Change/s requested to a policy in lapse
or cancel status will not be made. Customer understands that insurance
company processing of change request/s may take up to 6 weeks. Customer
must pay any bill/invoice they receive from the insurance company,
regardless if the change requested herein is reflected in the bill/invoice.
All fees are fully earned for services rendered regardless of policy
status and/or acceptance of change/s. Processing of change request
form/s by Big Dan's Insurance Agency does not insure that coverage
is now or has ever been in force.
____________________________________________________/_____________________
Customer's Signature / Date
Changes will not be processed without
signature.
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